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‘Diverting patients’: RI hospitals face new problems amid second wave of COVID-19

Target 12

PROVIDENCE, R.I. (WPRI) – With coronavirus hospitalizations soaring once again in Rhode Island, health experts are concerned about bed shortages and staffing issues that have already forced some hospitals to turn away ambulances this fall.

Rhode Island reported 46 people with coronavirus were admitted to the hospital last Thursday, marking the second most in a single day since the prior peak on May 1, and raising eyebrows among many across the state’s health care system.

“We’ve seen more hospitalized cases now than we did in the spring,” Care New England President and CEO Dr. James Fanale told Target 12.

State leaders have said repeatedly the hospitals are better positioned today than in the spring, especially when it comes to personal protective equipment and the availability of intensive care unit beds. The state has stockpiled a year-long supply of N95 masks, and the R.I. Department of Health reports 26 people with the virus were in the ICU Sunday, well below the peak of 93 on May 2.

But a Target 12 analysis of hospital diversion data — along with interviews with doctors, nurses, EMT workers, hospital executives and state health officials over the past two months — shows hospitals have increasingly had to turn away incoming ambulances, at one point reaching almost double the rate seen last year.

“What we’re seeing is very different than the first wave,” said Dr. Otis Warren, Rhode Island president of the American College of Emergency Physicians, a professional group representing more than 200 emergency care doctors across the state.

“We’re seeing not only high numbers of COVID patients, but also high numbers of every other type of patient,” Warren added. “It’s created a real crunch across the state in our hospitals.”

In March, horrifying stories about overflowing New York City hospitals spurred Gov. Gina Raimondo to order a halt to all elective procedures and surgeries in Rhode Island in an effort to maintain capacity for coronavirus patients.

The governor also quickly moved to designate three field hospitals and repeatedly asked Rhode Islanders to avoid the emergency room unless absolutely necessary. The mandate and messaging had the desired effect of keeping hospital beds open and available for COVID-19 patients.

But it also stopped scores of people from seeking both emergency and preventative care, which ultimately translated into deferred treatment and pent-up demand that erupted shortly after elective procedures resumed.

By August, hospitals were brimming again with people who had put off certain medical needs – such as hip replacements and other scheduled procedures – along with patients who felt comfortable again going to the emergency room.

Providence EMS chief Zach Kenyon, who oversees seven ambulances that handle roughly 33,000 runs per year, said calls for service also returned to pre-pandemic levels, which he attributed in part to COVID fatigue.  

“People today are desensitized to COVID,” Kenyon told Target 12. “We’re right back to where we were.”

Ambulances diverted

The return of so many patients to the hospitals also resulted in a rapid increase of hospital diversions, which is when an emergency department turns away incoming ambulances because there isn’t enough room for that patient.

From March to May, when elective procedures weren’t allowed, Rhode Island hospitals reported only 14 diversions over three months. But they started rising in June, shortly after elective procedures were allowed again. In August, statewide diversions reached 91, representing an 82% increase compared to the same month a year earlier.

“Today, I learned most hospitals are diverting patients,” Raimondo said Tuesday during a weekly interview with 12 News. “People who continue to think this isn’t a big deal, you just need to know that it’s hurting people. If it’s your child in an ambulance going to the hospital and they divert it someplace else, how would you feel?”

Hospitals go on diversion for multiple reasons, and there are exceptions such as trauma victims, who are never turned away. Emergency departments also never turn away anyone who comes in on their own.

But often diversions are the result of a bottleneck created in the flow of patients moving from emergency rooms to in-patient care and then finally discharged from the facility.

“If there’s no bed upstairs in the hospital, these patients tend to wait in the emergency department sometimes for many hours, sometimes for days,” Warren explained. “In talking with my colleagues across the state, it’s a really tough job to do when we want to see patients, but we have no place to admit them.”  

The recent bottleneck has stemmed from a holdup in discharges, according to Fanale, who said hospitals right now have high numbers of older adults and behavioral-health patients. These groups are getting stuck at the hospitals, he explained, because nursing homes are wary about taking in new patients after their experience early in the public health crisis.

The state’s behavioral health facilities are also already jam-packed with patients, making it difficult to transfer people who come into the health system through the emergency room, he added.

“We have patients sitting in the hospital waiting to be discharged,” Fanale said. “If we were able to get them moved to a contracted nursing home or something else, we’d have more bed availability.”  

The point was reiterated by Lifespan spokesperson Kathleen Hart, who said Rhode Island Hospital emergency department volume is actually slightly below pre-COVID levels. But that doesn’t help with the inflow and outflow of patients, she said.

“A main driver for hospital diversion is our inability to discharge patients from the hospital when they are ready to be discharged,” she said. “We are seeing significant delays in discharge to skilled nursing facilities and other congregate living settings due to COVID testing and quarantine requirements imposed by those settings.”  

A staffing shortage

Hospital diversions were once rare in Rhode Island, but they started becoming more common after Memorial Hospital closed its emergency room in 2018, according to a Target 12 review of annual hospital diversion data dating back to 2015.

Last year Rhode Island Hospital – with the largest emergency department in the state – spent 739 hours on diversion, which is the equivalent of sending ambulances away for an entire month. More recently, Rhode Island Hospital diversions have returned to prior-year levels, but Hart nonetheless said the hospital is prepared for the ongoing surge of COVID hospitalizations.

“We have been anticipating this surge for the past few months,” Hart said. “While the supply changes on a daily basis, Lifespan hospitals are currently positioned with the resources necessary.”

Since June, Kent Hospital in Warwick has reported the most diversions. Fanale attributed the problem to a staffing shortage, highlighting how diversions aren’t always directly associated with bed shortages. Without adequate staffing levels, ambulances can get turned away even though hospital beds are empty.

“It’s been the source of an extreme amount of stress and personal workload over the last four weeks,” Fanale said about the Kent diversions. “We had a challenging staffing situation a year ago before the pandemic. As we staffed up, guess what happened? The pandemic hit.”

Fanale claims Kent has turned a corner over the last week, saying Care New England has spent about $2 million to revamp operations and add staff aimed at ending the diversions. But he acknowledged that recruiting and training workers has also become more complicated in recent months, which isn’t unique to Care New England or the state.

Rhode Island – along with most of the Northeast and the West Coast – was hit earlier than other parts of the country, allowing hospitals to hire temporary workers – such as traveling nurses – to fill shortages.

Today, coronavirus cases and hospitalizations are soaring across the country, meaning health care facilities are competing for extra help in every state, and nurses in particular are in high demand.

United Nurses and Allied Professionals spokesperson Ray Sullivan pointed to the spring, when some nurses were traveling to help in New York City. That’s less likely to happen these days, he said.

“Now we’re in the midst of this second wave and geographically there are less places for people to draw from because the virus has had such a broad impact over the summer and late fall,” Sullivan said.  

Like the rest of the state, the nurses union has also seen a recent spike in cases among front-line workers, which has added to the staffing problems. During the second half of October, cases among health care workers increased 53% compared to the first half of the month, according to Health Department spokesperson Joseph Wendelken.  

“There’s been a dramatic spike in positive tests over the last month and that’s across the state in all the hospitals that we represent,” Sullivan said. “It’s impacting everything.”

Health outcomes and an economy at-risk

Despite the multifaceted challenges percolating beneath the surface at hospitals, there wasn’t much of an appetite among the people interviewed by Target 12 to scale back elective surgeries and procedures, or to dissuade Rhode Islanders again from seeking non-COVID care.

Even with coronavirus hospitalizations topping 200 people last week for the first time since May, many health care providers said the industry remains equally alarmed by how sick some people became over the spring and summer because they put off procedures and treatment unrelated to COVID.

“At this point, we don’t believe we should be scaling back on elective surgeries or procedures as we found during the initial surge that most surgeries and procedures are not truly elective,” Hart said.   

There’s also concern among state leaders and hospital executives about dealing another business blow to the health care industry, which accounts for about 30% of the state’s economy and is the largest private-sector employer.

“If we shut down elective surgeries, it’s going to put your hospitals into financial peril that we may never come back from again,” Fanale said.

Care New England, the state’s second largest hospital system, saw its revenue plummet during the earlier part of the year, which Fanale said was fueled by the pandemic and the inability to receive federal relief money at specialty hospitals like Butler.

Lifespan, the state’s largest hospital system, has received $130 million through the CARES Act, and its chief financial officer told bondholders in September the federal money offset roughly the entire drop in revenue they experienced during the spring quarter.

As for Raimondo, who made the decision earlier this year to stop elective procedures, she expressed optimism that the state’s existing hospitals – along with a 300-bed field hospital that remains open in Cranston – will be enough to deal with the current coronavirus wave. And she expressed no interest in scaling back non-COVID operations at hospitals again.

“Frankly, the hospitals will go out of business,” she said.

Eli Sherman (esherman@wpri.com) is a Target 12 investigative reporter for WPRI 12. Follow him on Twitter and on Facebook.

Tim White (twhite@wpri.com) is the Target 12 investigative reporter and host of Newsmakers for WPRI 12 and Fox Providence. Follow him on Twitter and on Facebook

Kim Kalunian contributed to this report.

Copyright 2020 Nexstar Inc. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.

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